Endgames Picture Quiz

A hand flexion contracture with progression

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6137 (Published 30 October 2014) Cite this as: BMJ 2014;349:g6137
  1. Niall M McInerney, plastic surgery specialist registrar1,
  2. Michael O’Shaughnessy, consultant plastic surgeon1,
  3. James Clover, consultant plastic surgeon1
  1. 1Department of Plastic and Reconstructive Surgery, Cork University Hospital, Cork, Republic of Ireland
  1. Correspondence to: N M McInerney nmac{at}ymail.com

A 65 year old male retired farmer presented with an inability to fully straighten the ring finger and little finger of his right hand. This had progressed over the past two years and he had recently noticed a “rope like” swelling in his palm. He had no history of trauma and no medical history of note, except that he had smoked until 10 years earlier and had a 90 pack year history. His father had a similar deformity.

Examination showed palpable cords to his middle, ring, and little fingers. He had palpable nodules on the volar aspect of all proximal phalanges, which caused flexion contractures of the proximal interphalangeal joints. The cord and nodules in the ring finger were adherent to the overlying skin. The most severe flexion contractures were seen in the ring finger, with 25° and 36° contractures of the metacarpophalangeal joints and proximal interphalangeal joints, respectively (fig 1).

Fig 1 Contractures of the metacarpophalangeal and proximal interphalangeal joints of the ring finger and little finger of the right hand. The skin was affected on the volar aspect of the metacarpophalangeal joint of the ring finger (outlined in blue; A)

Questions

  • 1. What is the most likely diagnosis?

  • 2. What are the presenting signs of this condition?

  • 3. What is the differential diagnosis?

  • 4. What are the surgical options?

  • 5. Are non-surgical options available?

Answers

1. What is the most likely diagnosis?

Short answer

Dupuytren’s disease.

Long answer

The most likely diagnosis is Dupuytren’s disease.1 This is a fibroproliferative disease of the palmar fascia, which can lead to permanent flexion contractures of affected digits.

Dupuytren’s disease mainly affects older men of northern European descent. Prevalence ranges from 0.6% to 31.6% in general populations in Western countries and increases with age.2 The disease has a strong genetic component, which had been attributed to an autosomal dominant gene of …

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